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An ASCO Policy Statement has been issued on cancer prevention in an effort to heighten awareness of the integral role of oncologists in providing cancer prevention services.
As oncologists have gained a greater understanding of carcinogenesis and cancer susceptibility, their ability to intervene has expanded beyond cancer treatment to include risk assessment and prevention counseling. To heighten awareness of the integral role of oncologists in providing cancer prevention services, ASCO has issued an ASCO policy statement on cancer prevention, which was published online in December (http:www.jco.org).1
The policy statement was developed by ASCO's Cancer Prevention Committee (CaPC), which was established in 2002 with a charge to facilitate the inclusion of cancer risk assessment and prevention counseling as an integral part of oncology practice. The statement is not intended to be a comprehensive overview of cancer prevention or a practice guideline; rather, it is designed to fulfill five key purposes1:
According to a 2004 survey of ASCO members, many practicing oncologists in the United States incorporate a variety of cancer prevention and/or screening activities into their practices regularly, either by direct provision or through referral.2 “Oncologists will have an increasing role in providing prevention and risk reduction services for their patients, and these services will become more complex as the understanding of cancer susceptibility and the long-term effects of cancer therapies evolve,” says Robin Zon, MD, FACP, Michiana Hematology-Oncology, PC (Southbend, Indiana), the Clinical Practice Committee Liaison to the CaPC and the first author of the ASCO statement.
The policy statement outlines several risk assessment and prevention activities that should fall under the purview of oncologists. Risk assessment is recommended for individuals in whom cancer has developed as the result of an inherited predisposition, and the statement notes that oncologists are well-positioned to identify such individuals.1 These individuals will benefit from genetic counseling and testing and a discussion of risk-reduction strategies, such as prophylactic surgery, increased screening, and chemoprevention. Behavioral modifications are the focus of prevention activities, as lifestyle factors have been found to contribute substantially to cancer-related deaths. The primary behavioral modification is tobacco cessation, and counseling about cessation is essential for reducing the risk of several types of cancer, especially lung cancer. Other prevention activities discussed in the policy statement include counseling regarding diet, physical exercise, obesity, and exposure to ultraviolet radiation.1
Although many practicing oncologists provide risk assessment and prevention counseling to their patients, substantial barriers remain. In the 2004 survey of ASCO members, 65% of respondents agreed with the statement, “There is insufficient reimbursement for prevention activities in my clinical practice.”2 The following year, the Centers for Medicare & Medicaid Services (CMS) established coverage for tobacco cessation counseling (with two Current Procedural Terminology codes for counseling) and reimbursement for two cessation attempts per year (with up to four interventions for each attempt).3 However, few claims for cessation counseling have been submitted by Medicare providers (including oncologists).4 A subsequent study of Medicare and private payer reimbursement policies showed that third-party reimbursement is available for many cancer prevention counseling services for patients with an established cancer diagnosis, a precancerous condition, or a high risk of familial cancer, primarily through established evaluation and management (E/M) codes.5
Time is another important factor, especially with regard to hereditary cancer risk assessment and counseling. Such assessment is complex, and a comprehensive explanation of the issues is time-consuming. In addition, it is not clear how best to document and bill for this type of counseling, and payer policies have not been firmly established.1 Nonetheless, many oncologists may not be aware of reimbursement methods for genetic testing and counseling services when they are available (see sidebar).
Another barrier is the comfort level of oncologists. In the 2004 ASCO survey, 43% of respondents said they needed more information on cancer prevention services in order to be comfortable providing them.2 ASCO has enhanced efforts to address this gap through the development of a variety of resources, including the ASCO Curriculum: Cancer Prevention, the ASCO Curriculum: Cancer Genetics & Genetic Susceptibility Testing, and the Cancer Prevention track at the ASCO Annual Meeting.
Role clarity may be another barrier to providing cancer prevention services. The primary care provider is the source for screening and prevention services for average risk individuals, while the oncologist is the source of prevention services for his or her own cancer survivors, who are at risk for second cancers, and is the point of referral for patients at high risk for the development of primary cancer.6 However, the maximum benefit of preventive care among cancer survivors has been achieved when follow-up care is provided by both a medical oncologist, ensuring cancer surveillance, in collaboration with a primary care provider.7,8 Dr Zon points out further benefit: “We cannot overlook that many of the behavioral interventions we recommend as prevention and risk reduction interventions will benefit other health-related issues and the overall health of the individual.”
Oncologists are uniquely poised to assume a leadership role in risk assessment and prevention services because of their expertise in evaluating the strength of evidence for cancer prevention and early detection, and in integrating these findings into standard clinical practice. “Oncologists are looked on as thought leaders in their health system,” notes Phillip J. Stella, MD, of St Joseph's-Mercy Hospital (Ann Arbor, Michigan), who also serves on the CaPC. Dr Stella capitalized on this by leading an initiative in his community health care system to develop a system-wide smoking cessation program. Dr Stella describes the program, which launched on November 19, 2008, as “smoking cessation in a box,” with a package of resources (information on drugs and cessation methods, patient materials, and billing instructions) sent to a designated “champion” in each primary care physician's office within the health care system, who will also be trained in how to counsel patients about smoking cessation. “Billing is only one piece of the problem,” says Dr Stella. “You also need to train the health care professionals about how to provide effective counseling.” Dr Stella credits his involvement with the CaPC for raising his awareness of the need to act. “I recognized that smoking cessation was an important issue that everyone gives lip service to but few act on. Oncologists need to step up on this and other cancer prevention issues.”
Dr Zon agrees that oncologists should assume a leadership position. “We can play a key role by collaborating with and educating our local primary care colleagues and hospitals/community health centers regarding the delivery of prevention services,” says Dr Zon. She notes that tumor boards, hospital-based lectures, and oncology care committees provide opportunities for oncologists to educate primary care physicians about the most current information on cancer prevention. In addition, oncologists should continue to participate in health screenings and other community efforts to help the general public engage in healthy lifestyles that help to reduce the risk of cancer.
ASCO encourages its members to review the policy statement on cancer prevention to better understand the Society's perspective on the role of oncologists in risk assessment and cancer prevention counseling. ASCO members should also avail themselves of the Society's educational resources on cancer prevention to enhance their ability to provide high-quality care to their patients.
Genetic counseling is an increasingly important service for oncology patients. Practices are working to develop sustainable models to provide and bill for these services.
Code 96040 was introduced in Current Procedural Terminology (CPT) on January 1, 2007. This code is defined as “medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family.” The CPT manual indicates that the code is intended to be used for services provided by trained genetic counselors. While the introduction of this code is clearly a positive step, this has not resolved the billing uncertainties, as 96040 is not payable by Medicare and non-Medicare payers have varying coverage and payment policies.
In 2006, ASCO commissioned Avalere Health, LLC to conduct a limited study of Medicare (four carriers) and private payer (six payers) reimbursement policies. While this survey focused on coverage for prevention services, payers were also asked about coverage policy for genetics services. Five of six non-Medicare health plans in this survey noted that they cover genetic counseling services. This survey was done before the introduction of CPT 96040 so coverage for this code is undetermined.
Table 1 identifies three common scenarios for the provision and billing of genetic counseling services and provides broad guidance for billing to Medicare and private payers.